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Judul Anamnesa

Keluhan Utama

Riwayat keluhan

1.   Riwayat Pengobatan : 2.  Riwayat menstruasi:'     Menarche umur : . . .thn. menstruasi terakhir tanggal :     Siktus : . . . . . . hari, (    ) teratur   (    ) tidak teratur, lama:. . . . . .hari, volume : . . . . . . .cc     Keluhan saat haid: . . . . . . 3.  Riwayat perkawinan     Status : (    ) belum kawin  (    ) cerai  (    ) kawin, . . . kali, umur waktu pertama kawin :. . . . . . . . . .thn 4.  Riwayat kehamilan, persalinan dan nifas yang lalu <table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="960" style="width: 720pt;">
 <tbody><tr style="mso-yfti-irow:0;mso-yfti-firstrow:yes;height:15.0pt">
 <td width="29" rowspan="3" style="width:21.95pt;border:solid windowtext 1.0pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 No<o:p></o:p>
 </td>
 <td width="51" rowspan="3" style="width:38.2pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Tgl Partus<o:p></o:p>
 </td>
 <td width="192" nowrap="" colspan="3" style="width:144.0pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-top-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Umur hamil<o:p></o:p>
 </td>
 <td width="51" rowspan="3" style="width:38.2pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Jenis Partus<o:p></o:p>
 </td>
 <td width="128" nowrap="" colspan="2" valign="bottom" style="width:96.0pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-top-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Penolog<o:p></o:p>
 </td>
 <td width="117" nowrap="" colspan="3" style="width:88.0pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-top-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Anak<o:p></o:p>
 </td>
 <td width="294" nowrap="" colspan="4" valign="bottom" style="width:220.65pt;
 border:solid windowtext 1.0pt;border-left:none;mso-border-top-alt:solid windowtext .5pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Keadaan anak sekarang<o:p></o:p>
 </td>
 <td width="97" nowrap="" colspan="2" valign="bottom" style="width:73.0pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-top-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Menyusui<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:1;height:15.0pt">
 <td width="66" nowrap="" rowspan="2" style="width:49.6pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Abortus<o:p></o:p>
 </td>
 <td width="78" nowrap="" rowspan="2" style="width:58.7pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Prematur<o:p></o:p>
 </td>
 <td width="48" nowrap="" rowspan="2" style="width:35.7pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Atern<o:p></o:p>
 </td>
 <td width="75" nowrap="" rowspan="2" style="width:56.3pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Nakes<o:p></o:p>
 </td>
 <td width="53" nowrap="" rowspan="2" style="width:39.7pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Non<o:p></o:p>
 </td>
 <td width="53" colspan="2" style="width:40.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-top-alt:solid windowtext .5pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 JK<o:p></o:p>
 </td>
 <td width="64" nowrap="" rowspan="2" style="width:48.0pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 BBL<o:p></o:p>
 </td>
 <td width="230" nowrap="" colspan="2" valign="bottom" style="width:172.65pt;
 border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;
 border-right:solid windowtext 1.0pt;mso-border-top-alt:solid windowtext .5pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-bottom-alt:solid windowtext .5pt;
 mso-border-right-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;
 height:15.0pt">
 Hidup<o:p></o:p>
 </td>
 <td width="64" nowrap="" colspan="2" rowspan="2" style="width:48.0pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 meninggal<o:p></o:p>
 </td>
 <td width="31" nowrap="" rowspan="2" valign="bottom" style="width:23.6pt;border-top:
 none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Ya<o:p></o:p>
 </td>
 <td width="66" nowrap="" rowspan="2" valign="bottom" style="width:49.4pt;border-top:
 none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Tidak<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:2;height:15.0pt">
 <td width="27" style="width:20.0pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="27" nowrap="" valign="bottom" style="width:20.0pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="112" nowrap="" valign="bottom" style="width:84.3pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Normal<o:p></o:p>
 </td>
 <td width="118" style="width:88.35pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 cacat<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:3;height:15.0pt">
 <td width="29" nowrap="" valign="bottom" style="width:21.95pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-left-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 2.<o:p></o:p>
 </td>
 <td width="51" nowrap="" valign="bottom" style="width:38.2pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="66" nowrap="" valign="bottom" style="width:49.6pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="78" nowrap="" valign="bottom" style="width:58.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="48" nowrap="" valign="bottom" style="width:35.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="51" nowrap="" valign="bottom" style="width:38.2pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="75" nowrap="" valign="bottom" style="width:56.3pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="53" nowrap="" valign="bottom" style="width:39.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="27" nowrap="" valign="bottom" style="width:20.0pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="27" nowrap="" valign="bottom" style="width:20.0pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="64" nowrap="" valign="bottom" style="width:48.0pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="112" nowrap="" valign="bottom" style="width:84.3pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="118" nowrap="" valign="bottom" style="width:88.35pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="32" nowrap="" valign="bottom" style="width:24.0pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="32" nowrap="" valign="bottom" style="width:24.0pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="31" nowrap="" valign="bottom" style="width:23.6pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="66" nowrap="" valign="bottom" style="width:49.4pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
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  <o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:4;height:15.0pt">
 <td width="29" nowrap="" valign="bottom" style="width:21.95pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-left-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 3.<o:p></o:p>
 </td>
 <td width="51" nowrap="" valign="bottom" style="width:38.2pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="66" nowrap="" valign="bottom" style="width:49.6pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="78" nowrap="" valign="bottom" style="width:58.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="48" nowrap="" valign="bottom" style="width:35.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="51" nowrap="" valign="bottom" style="width:38.2pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="75" nowrap="" valign="bottom" style="width:56.3pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="53" nowrap="" valign="bottom" style="width:39.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
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  <o:p></o:p>
 </td>
 <td width="27" nowrap="" valign="bottom" style="width:20.0pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
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  <o:p></o:p>
 </td>
 <td width="27" nowrap="" valign="bottom" style="width:20.0pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="64" nowrap="" valign="bottom" style="width:48.0pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="112" nowrap="" valign="bottom" style="width:84.3pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="118" nowrap="" valign="bottom" style="width:88.35pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="32" nowrap="" valign="bottom" style="width:24.0pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
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<o:p> </o:p>5   Riwayat KB terakhir : (   ) tidak  (    )ya,jenis : . . . . . . . lama pemakaian : . . . . . . . .6   Riwayat hamil ini :     Hari pertama haid terakhir  (HPHT) : . . . . . . . . . . Tafsiran      partus: . . . . . . . .     ANC : (      ) Ya     (     ) Tidak     Keluhan saat hamil : (     ) Tidak ada (    ) Mual Muntah   (    )Peradarahan   (   ) Sakit Kepala  (  ) Lainnya7.  Riwayat penyakit yang lalu/indikasi operasi     (    ) Hipertensi  (    ) Kencing manis  (   ) Jantung   (    ) HIV  (     ) Hepatitis: . . . . . . .     (     )Lainnya . . . . . . . . . . . .  (     ) Tidak Jelas8.  Riawayat Alergi:   (    ) TIdak   (    ) ya     -Obat : . . . . . . . . .     -Makanan : . . . . . . . .     -Lain-lain : . . . . .  . .  .9.   Riwayat penyakit gynekologi                (    ) Tidak ada  (   ) ada, jenis:  (   ) infertilitas  (    ) infeksi virus  (     ) PMS  (    ) Cesvisitis kronis  (   )               endometriosis (    ) myoma (    ) Polip cervix (    ) kanker (    ) operasi kandungan  (    ) lainnya . . . . .

Judul Pemeriksaan Fisik

Data Objektif

1.    Pemeriksaan fisik : KU . . . . . . . . .Kesadaran. . . . . . . . .GCS: E. . . . . . . . . .V . . . . . . .M . . . . . . .       BB : . . . . . . .kg,  TB :. . . . . . . .cm, TD : . . . . . . ./ . . . . . . .mmHg, Nadi : . . . . . . . .x/mnt,   Suhu :     C       Pernafasan : . . . . . . .x/mnt, SaO2:. . . . . .% 2    Pemeriksaan Fisik      Mata :  Konjunctiva : (   )pucat  (    ) normal  Sklera : (   ) putih  (    ) kuning  (   ) merah      Leher : Tyroid : (   ) teraba (   ) tidak teraba      Dada : Jantung : . . . . . . . . . . . . . .      Paru : . . . . . . . . . . . . .      Mama : bentuk : (    ) simetris (    ) asimetris, putting susu : (   )menonjol  (    ) datar  (    ) masuk       Pengeluaran :  (    ) tidak ada  (    )  ada  (    ) Colostrum  (   ) ASI  (    ) nanah  (   ) darah      Kebersihan :  (    ) cukup  (   ) kurang,  (   ) kelainan :  (   ) lecet  (    ) bengkak  (    )  lainnya . . . . . . . . . . .      Extremitas : tungkai: (   ) simetris (   ) asimetris,  edema: (    ) + (    ) -

Pemeriksaan Khusus / Obstetri

3.    Pemeriksaan Khusus / Obstetria.    Abdomen*inspeksi: Luka bekas operasi : (   ) tidak ada (   ) ada Arah pembesaran :  (   ) tidak ada (   ) ada:  (   ) memanjang  (    ) melebar Kelamin :  (   ) tidak ada (    ) ada: (   ) distensi  (    ) lainnya . . . . . . . . . . . *Palpasi :TFU : . . . . . . . cm, taksiran berat janin :. . . . . . . . Gram.Letak punggung:  (   ) puka  (   ) pukiPressentasi :  (    ) kepala (    ) bokong   (    ) kosongBagian terendah: . . . . . ./ . . . . . .(perlimaan)Konstraksi uterus : (   ) tidak ada  (   )ada: (    ) baik   (    ) lembekHis . . . . . . . . . . .x/10mnt, lama : . . . . . . . . . .detikKelainan :  (    ) nyeri tekan   (    ) cekungan pada perut (    ) blass penuhTeraba massa : (    ) tidak ada  (   ) ada: (   ) solid (    ) kistik, ukuran: . . . . . . . . . x . . . . . .cm Auskultasi :  bising usus : (   ) ada  (   ) tidak ada                       DJJ : . . . . . . . .x/mnt

Ginekologi

b.   Ginekologi Inspeksi : Pengeluaran pervaginam : (   ) tidak ada (   ) ada (   ) darah (   ) lendir (    ) air ketuban (   ) tali pusat                                                 (    ) bagian kecil janin (   ) nanahLochea :  (   ) tidak ada (   )ada: (   ) rubra (   ) sanguinolenta(   ) alba   (    ) lainnya . . . . . . . . . . . . . .Volume: . . . . . . . . . .cc, berbau: (   ) tidak (  ) ya, bau: (   ) amis   (   ) busukPerinium : (    ) utuh  (   ) Laserasi : derajat . . . . . . .Jahitan: (    ) baik  (   ) terlepas (    ) hematom (   ) oedem  (   ) ekimosis  (   ) kemerahan Inspekulo vagina: Vagina: kelainan:(   ) tidak ada (   ) ada  (   ) fistel  (   )condiloma  (   ) septum (    ) varises  (    ) lainnya . . . . .Hymen : (   ) utuh(    )robek: sampai dasar, arah robekan (jam) . . . . . . . .keadaan sekitar robekan . . . . . . . . . .Portio : (   ) utuh   (   ) rapuh   (   ) lainnya  Cavum douglasi : menonjol :  (    ) tidak   (   )  ya   Vagina toucher: Oleh . . . . . . . . . . . . .tgl/jam . . . . . . . . . . . . . Pemeriksaan Panggul : Promontorium . . . . . . . . . . . . . . . . . . . . . Linea Innominata . . . . . . . . . . . . . . . . . . .  Arcus Pubis . . . . . . . . . . . . . . . . . . . . . . . Spina Ischiadica . . . . . . . . . . . . . . . . . . . Os coxygeus . . . . . . . . . . . . . . . . . . . Kesan Panggul : . . . . . . . . . . .

Pemeriksaan Khusus / Obstetri

3.    Pemeriksaan Khusus / Obstetria.    Abdomen*inspeksi: Luka bekas operasi : (   ) tidak ada (   ) ada Arah pembesaran :  (   ) tidak ada (   ) ada:  (   ) memanjang  (    ) melebar Kelamin :  (   ) tidak ada (    ) ada: (   ) distensi  (    ) lainnya . . . . . . . . . . . *Palpasi :TFU : . . . . . . . cm, taksiran berat janin :. . . . . . . . Gram.Letak punggung:  (   ) puka  (   ) pukiPressentasi :  (    ) kepala (    ) bokong   (    ) kosongBagian terendah: . . . . . ./ . . . . . .(perlimaan)Konstraksi uterus : (   ) tidak ada  (   )ada: (    ) baik   (    ) lembekHis . . . . . . . . . . .x/10mnt, lama : . . . . . . . . . .detikKelainan :  (    ) nyeri tekan   (    ) cekungan pada perut (    ) blass penuhTeraba massa : (    ) tidak ada  (   ) ada: (   ) solid (    ) kistik, ukuran: . . . . . . . . . x . . . . . .cm Auskultasi :  bising usus : (   ) ada  (   ) tidak ada                       DJJ : . . . . . . . .x/mnt

Judul Anamnesa

Judul Pemeriksaan Fisik

ALERGI

Riwayat keluhan

1.   Riwayat Pengobatan : 2.  Riwayat menstruasi:'     Menarche umur : . . .thn. menstruasi terakhir tanggal :     Siktus : . . . . . . hari, (    ) teratur   (    ) tidak teratur, lama:. . . . . .hari, volume : . . . . . . .cc     Keluhan saat haid: . . . . . . 3.  Riwayat perkawinan     Status : (    ) belum kawin  (    ) cerai  (    ) kawin, . . . kali, umur waktu pertama kawin :. . . . . . . . . .thn 4.  Riwayat kehamilan, persalinan dan nifas yang lalu <table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="960" style="width: 720pt;">
 <tbody><tr style="mso-yfti-irow:0;mso-yfti-firstrow:yes;height:15.0pt">
 <td width="29" rowspan="3" style="width:21.95pt;border:solid windowtext 1.0pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 No<o:p></o:p>
 </td>
 <td width="51" rowspan="3" style="width:38.2pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Tgl Partus<o:p></o:p>
 </td>
 <td width="192" nowrap="" colspan="3" style="width:144.0pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-top-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Umur hamil<o:p></o:p>
 </td>
 <td width="51" rowspan="3" style="width:38.2pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Jenis Partus<o:p></o:p>
 </td>
 <td width="128" nowrap="" colspan="2" valign="bottom" style="width:96.0pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-top-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Penolog<o:p></o:p>
 </td>
 <td width="117" nowrap="" colspan="3" style="width:88.0pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-top-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Anak<o:p></o:p>
 </td>
 <td width="294" nowrap="" colspan="4" valign="bottom" style="width:220.65pt;
 border:solid windowtext 1.0pt;border-left:none;mso-border-top-alt:solid windowtext .5pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Keadaan anak sekarang<o:p></o:p>
 </td>
 <td width="97" nowrap="" colspan="2" valign="bottom" style="width:73.0pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-top-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Menyusui<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:1;height:15.0pt">
 <td width="66" nowrap="" rowspan="2" style="width:49.6pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Abortus<o:p></o:p>
 </td>
 <td width="78" nowrap="" rowspan="2" style="width:58.7pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
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 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Prematur<o:p></o:p>
 </td>
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 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Atern<o:p></o:p>
 </td>
 <td width="75" nowrap="" rowspan="2" style="width:56.3pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
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 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Nakes<o:p></o:p>
 </td>
 <td width="53" nowrap="" rowspan="2" style="width:39.7pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
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 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Non<o:p></o:p>
 </td>
 <td width="53" colspan="2" style="width:40.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
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 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 JK<o:p></o:p>
 </td>
 <td width="64" nowrap="" rowspan="2" style="width:48.0pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
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 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 BBL<o:p></o:p>
 </td>
 <td width="230" nowrap="" colspan="2" valign="bottom" style="width:172.65pt;
 border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;
 border-right:solid windowtext 1.0pt;mso-border-top-alt:solid windowtext .5pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-bottom-alt:solid windowtext .5pt;
 mso-border-right-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;
 height:15.0pt">
 Hidup<o:p></o:p>
 </td>
 <td width="64" nowrap="" colspan="2" rowspan="2" style="width:48.0pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 meninggal<o:p></o:p>
 </td>
 <td width="31" nowrap="" rowspan="2" valign="bottom" style="width:23.6pt;border-top:
 none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Ya<o:p></o:p>
 </td>
 <td width="66" nowrap="" rowspan="2" valign="bottom" style="width:49.4pt;border-top:
 none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Tidak<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:2;height:15.0pt">
 <td width="27" style="width:20.0pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="27" nowrap="" valign="bottom" style="width:20.0pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="112" nowrap="" valign="bottom" style="width:84.3pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Normal<o:p></o:p>
 </td>
 <td width="118" style="width:88.35pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 cacat<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:3;height:15.0pt">
 <td width="29" nowrap="" valign="bottom" style="width:21.95pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-left-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 2.<o:p></o:p>
 </td>
 <td width="51" nowrap="" valign="bottom" style="width:38.2pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="66" nowrap="" valign="bottom" style="width:49.6pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="78" nowrap="" valign="bottom" style="width:58.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="48" nowrap="" valign="bottom" style="width:35.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="51" nowrap="" valign="bottom" style="width:38.2pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="75" nowrap="" valign="bottom" style="width:56.3pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="53" nowrap="" valign="bottom" style="width:39.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="27" nowrap="" valign="bottom" style="width:20.0pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
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 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
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  <o:p></o:p>
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 <td width="64" nowrap="" valign="bottom" style="width:48.0pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="112" nowrap="" valign="bottom" style="width:84.3pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="118" nowrap="" valign="bottom" style="width:88.35pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
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 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
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  <o:p></o:p>
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  <o:p></o:p>
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 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
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  <o:p></o:p>
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 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
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  <o:p></o:p>
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 <tr style="mso-yfti-irow:4;height:15.0pt">
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 3.<o:p></o:p>
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  <o:p></o:p>
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  <o:p></o:p>
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  <o:p></o:p>
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  <o:p></o:p>
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 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
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  <o:p></o:p>
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  <o:p></o:p>
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  <o:p></o:p>
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  <o:p></o:p>
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  <o:p></o:p>
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<o:p> </o:p>5   Riwayat KB terakhir : (   ) tidak  (    )ya,jenis : . . . . . . . lama pemakaian : . . . . . . . .6   Riwayat hamil ini :     Hari pertama haid terakhir  (HPHT) : . . . . . . . . . . Tafsiran      partus: . . . . . . . .     ANC : (      ) Ya     (     ) Tidak     Keluhan saat hamil : (     ) Tidak ada (    ) Mual Muntah   (    )Peradarahan   (   ) Sakit Kepala  (  ) Lainnya7.  Riwayat penyakit yang lalu/indikasi operasi     (    ) Hipertensi  (    ) Kencing manis  (   ) Jantung   (    ) HIV  (     ) Hepatitis: . . . . . . .     (     )Lainnya . . . . . . . . . . . .  (     ) Tidak Jelas8.  Riawayat Alergi:   (    ) TIdak   (    ) ya     -Obat : . . . . . . . . .     -Makanan : . . . . . . . .     -Lain-lain : . . . . .  . .  .9.   Riwayat penyakit gynekologi                (    ) Tidak ada  (   ) ada, jenis:  (   ) infertilitas  (    ) infeksi virus  (     ) PMS  (    ) Cesvisitis kronis  (   )               endometriosis (    ) myoma (    ) Polip cervix (    ) kanker (    ) operasi kandungan  (    ) lainnya . . . . .

Skala Nyeri :

Sumber Data

Tgl

Nyeri Tulang, dengan

Keluhan Utama

Judul Penilaian Nyeri

Jenis Kelamin

Ginekologi

b.   Ginekologi Inspeksi : Pengeluaran pervaginam : (   ) tidak ada (   ) ada (   ) darah (   ) lendir (    ) air ketuban (   ) tali pusat                                                 (    ) bagian kecil janin (   ) nanahLochea :  (   ) tidak ada (   )ada: (   ) rubra (   ) sanguinolenta(   ) alba   (    ) lainnya . . . . . . . . . . . . . .Volume: . . . . . . . . . .cc, berbau: (   ) tidak (  ) ya, bau: (   ) amis   (   ) busukPerinium : (    ) utuh  (   ) Laserasi : derajat . . . . . . .Jahitan: (    ) baik  (   ) terlepas (    ) hematom (   ) oedem  (   ) ekimosis  (   ) kemerahan Inspekulo vagina: Vagina: kelainan:(   ) tidak ada (   ) ada  (   ) fistel  (   )condiloma  (   ) septum (    ) varises  (    ) lainnya . . . . .Hymen : (   ) utuh(    )robek: sampai dasar, arah robekan (jam) . . . . . . . .keadaan sekitar robekan . . . . . . . . . .Portio : (   ) utuh   (   ) rapuh   (   ) lainnya  Cavum douglasi : menonjol :  (    ) tidak   (   )  ya   Vagina toucher: Oleh . . . . . . . . . . . . .tgl/jam . . . . . . . . . . . . . Pemeriksaan Panggul : Promontorium . . . . . . . . . . . . . . . . . . . . . Linea Innominata . . . . . . . . . . . . . . . . . . .  Arcus Pubis . . . . . . . . . . . . . . . . . . . . . . . Spina Ischiadica . . . . . . . . . . . . . . . . . . . Os coxygeus . . . . . . . . . . . . . . . . . . . Kesan Panggul : . . . . . . . . . . .

Data Objektif

1.    Pemeriksaan fisik : KU . . . . . . . . .Kesadaran. . . . . . . . .GCS: E. . . . . . . . . .V . . . . . . .M . . . . . . .       BB : . . . . . . .kg,  TB :. . . . . . . .cm, TD : . . . . . . ./ . . . . . . .mmHg, Nadi : . . . . . . . .x/mnt,   Suhu :     C       Pernafasan : . . . . . . .x/mnt, SaO2:. . . . . .% 2    Pemeriksaan Fisik      Mata :  Konjunctiva : (   )pucat  (    ) normal  Sklera : (   ) putih  (    ) kuning  (   ) merah      Leher : Tyroid : (   ) teraba (   ) tidak teraba      Dada : Jantung : . . . . . . . . . . . . . .      Paru : . . . . . . . . . . . . .      Mama : bentuk : (    ) simetris (    ) asimetris, putting susu : (   )menonjol  (    ) datar  (    ) masuk       Pengeluaran :  (    ) tidak ada  (    )  ada  (    ) Colostrum  (   ) ASI  (    ) nanah  (   ) darah      Kebersihan :  (    ) cukup  (   ) kurang,  (   ) kelainan :  (   ) lecet  (    ) bengkak  (    )  lainnya . . . . . . . . . . .      Extremitas : tungkai: (   ) simetris (   ) asimetris,  edema: (    ) + (    ) -

PENGKAJIAN AWAL MEDIS RAWAT INAP PENYAKIT KEBIDANAN & KANDUNGAN